Public Health Emergency Preparedness
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4. Additional Resources to Meet Surge Needs
Selecting an Alternative Care Site
Through discussions with General Lloyd Dodd, Command Surgeon for U.S.
Northern Command2 located at Peterson Air Force Base in Colorado Springs,
and his staff, the RMBT Working Group found there was a need to develop
a tool that assisted planners in identifying potential alternative care
sites in the event of a bioterrorist attack (Tool 1). Using existing buildings
and infrastructure is the most probable scenario should a surge medical
care facility need to be opened. The RMBT Working Group determined that
the use of existing buildings and infrastructure is feasible for this
region and would meet the needs of frontier, rural, urban and suburban
areas. The type of building that will need to be used is dependent upon
There are many alternatives for equipping an alternative care site once
selected. The Department of Defense presented and discussed many equipment
concepts with the Working Group. DoD equipment and personnel resources
include the Air Force Small Portable Expeditionary Aeromedical Rapid
Response (SPEARR), Expeditionary Medical Support (EMEDS), and Army field
hospitals. It is important to note that these are Federal resources and
may not be available for use during the initial days of response to a
bioterrorist attack. In addition, they require training in order for
local medical personnel to set-up and use the equipment with design alterations.
Another option included an 18-wheeler emergency response vehicle that
could be purchased by private carriers and would operate as a high-level
mobile medical care facility with an ambulatory surgical unit. This alternative
is costly—over $2.4 million—and provides a high level of care that may
not be feasible or cost effective for a large-scale medical response
The RMBT Working Group concluded that an alternative care site would
most likely be staffed and supplied by local and regional resources.
Three levels of supply caches were developed and are presented in the next section, Supplying and Staffing an Alternative Care Site. In the
event of a bioterrorist attack and when a region utilizes an alternative
care site, it is probable that one of levels of these caches would be
the asset deployed to equip the site to complete its functionality.
The RMBT Working Group agreed with the need to develop a simple tool
that could be used by regional planners to predict an appropriate alternative
care site from existing structures based on internal requirements. Hospital
engineers and facility personnel were presented with the infrastructure
requirements for an alternative care site outlined by the DoD4 and refined by the RMBT Working Group. This expert team assisted
with the development of an alternative care site selection matrix tool.
Through discussions with this team, they were able to identify additional
factors that should be considered in selecting an alternative care site.
When designing the tool, these factors were transformed into a matrix
with relative weights. The weights are based on a 5-point scale that
compares the alternative care site factor to that of a hospital. For
instance, if the potential alternative care site was a local high school, "Is
the ventilation system similar to a hospital or less adequate than that
of a hospital?"
The RMBT Working Group reviewed and tested the site selection tool matrix
during one of the RMBT Working Group meetings. The group was separated
into five breakout groups. Each group was provided with pictures and infrastructure
descriptions of three potential alternative care sites, an event center,
a church and a high school. Each group scored and ranked the three alternative
care sites for use in the event that is described in Chapter 8, Example of a Regional Exercise. Table 4 displays the scoring results from these
breakout groups (G = Group):
Table 4. Validating the Alternative Care Site Selection Matrix
The High School obtained the highest score (*) in all five groups and
therefore was the best choice for that particular biological event.
Issue areas discussed by the RMBT Working Group while testing the tool
- Is each factor of equal weight?
- If a factor is not applicable to the type of event it can be
- What if another use is already stated for the building in a
disaster situation? (i.e. a church may have a valuable community role.)
- This tool may be useful to use in a planning team including:
fire, law, Red Cross, security, hospital personnel such as the Local
Emergency Planning Commission (LEPC).
The alternative care site selection matrix tool (Table 5) is also available as an Excel file at www.ahrq.gov/research/altsites.htm.
2. The Department of Defense established U.S. Northern Command in 2002 to consolidate under a single unified command existing missions that were previously executed by multiple military units. The command's mission is homeland defense and civil support, specifically:
- Conduct operations to deter, prevent, and defeat threats and aggression aimed at the United States, its territories, and interests within the assigned area of responsibility.
- As directed by the President or Secretary of Defense, provide military assistance to civil authorities including consequence management operations.
3. Medical System Unit for Homeland Defense produced by the Mobile Medical International Corporation, St. Johnsbury, VT.
4. Skidmore S, Wall W, Church J. Modular Emergency Medical System Concept of Operation for the Acute Care Center: Mass Casualty Strategy for a Biological Terror Incident, May 2003.
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Supplying and Staffing an Alternative Care Site
One of the primary needs identified by the RMBT Working Group was to
develop supply and staffing recommendations for the operation of an alternative
care site or to augment the capability of a fixed care site, commonly
a hospital. It is unlikely that a hospital or alternative care site will
have much of the equipment or supplemental staff necessary to provide
care or support patient quarantine in the event of surge.
The concept of supplying an alternative care site was, interestingly
enough, well developed 5 decades ago with the establishment by the
U.S. Federal Civil Defense Agency and the Department of Health, Education,
and Welfare of the "Packaged Disaster Hospitals". These units
were available in 50 bed, 100 bed, and 200 bed units and contained supplies
and pharmaceuticals to provide reasonable medical care at an alternative
site. These "PDH"s were also accompanied by "Hospital
Reserve Disaster Inventory (HRDI)" for augmentation of hospital
capacity. Unfortunately, these units were dismantled and disposed of
in the 1980's.
The recognition of ongoing lack of ability for the medical care system
to quickly increase the capacity for patients that be cared for led us
to investigate a similar approach in terms of having cached material
that could be easily activated for increased surge capacity for patient
care. Three levels of supply caches were developed based upon available
resources and intent. These caches are similar to the old PDH model.
Level I cache parallels the HRDI concept of augmenting hospital capacity
and the Level II and III caches are a basic and advanced version of the
PDH type supplies. The following three example lists of caches are included
in Tool 2 and could be used to either augment hospital capacity or supply
an alternative care site at varying levels. Costs can vary widely; for
example, there is large variation in types of cots that can be purchased.
Level I: Hospital Augmentation Cache—Approximately $20,000 (Tool 2-I)
This list of supplies represents a most basic unit of supply support
for increased surge capacity of 50 patients, consisting only of items
that have very extended shelf life: cots, linens, masks, gowns, gloves,
IV poles, etc. No pharmaceuticals are included. This material is packed
in a trailer for mobility. It could be used as additional stocking for
an existent hospital (e.g., to set up a medical ward in a cafeteria, utilizing
other items as necessary from the hospital) or could offer supplies for
limited level care at an alternative care site. This list was created
by the RMBT Steering Committee and approved by the RMBT Working Group.
In our metropolitan area of 1,000,000 people and 11 hospitals, if each
hospital acquired a single cache, we would have a basic supply surge
capacity for 550 patients. Estimated cost for this cache (including trailer)
is approximately $20,000. One of these units has been purchased and is
currently being processed and positioned for potential use in our area.
Level II: Regional Alternative Site Cache—approximately $100,000 (Tool 2-II)
This list represents a more complete list of material to supply a regional
alternative care site for 500 patients. This level cache, or medical
armory, concept was developed by one of our partners, the Colorado Department
of Public Health and Environment, and approved by its Hospital Preparedness
Advisory Committee. This cache would be packaged in a modular fashion
so material to support multiples of 50 or 100 beds could be easily extracted
from the cache (similar in concept to the packaging of the Strategic
National Stockpile). Note that the supply list for this cache is more
complete, providing more expanded support for an alternative care site
compared with the Level I cache. Approximate price for a single cache
is less than $100,000. As with the Level I cache, pharmaceuticals are
excluded and only items with an extremely long shelf life are included.
It is assumed that the Strategic National Stockpile (SNS) would be requested
at the recognition of an event and would arrive within 72 hours to augment
these simple caches.
The list for the Level II cache is available from Robin Koons, Ph.D.,
at the Colorado Department of Public Health and Environment. Full contact
information is provided in Appendix A.
Level III: Comprehensive Alternative Care Site Cache—No cost estimate
currently available (Tool 2-III)
These comprehensive lists of equipment and consumables were adapted
by the RMBT Working Group from work done by the U.S. military and published
in The Concept of Operations for the Acute Care Center5, by the U.S.
Army Soldier and Biological Chemical Command (SBCCOM) (available at:
www.DenverHealth.org/BioTerror/Document.htm). These represent a specification
for a completely supplied 50-bed alternative care site consisting of
both long and short shelf life items. This represents a more complete
level of cache than the caches above. An attempt has been made to differentiate,
when possible, the needs of the unit when caring for infectious patients,
non-infectious patients and a situation when the unit would be used as
a simple quarantine unit. The initial specification also included pharmaceuticals,
but we have elected to not include them here as separate national, regional,
and local planning efforts are addressing this issue.
This extensive list has been separated into:
- Equipment Considerations.
- Patient Care Related Consumables.
- Administrative Consumables.
- Oxygen and Respiratory Related Equipment Considerations.
Note that this equipment
and the consumables can be pre-acquired and stored in a "medical
cache" as well. Consumable items may represent one of the greatest
challenges for establishing an alternative care site due to the number
and quantity of items. This comprehensive list also includes oxygen and
respiratory-related supplies that should be considered to provide limited
Special Consideration: Supplemental Oxygen Supply—approximately $13K-$480K
The majority of probable bioterrorism agents directly involve the respiratory
system, making supplemental oxygen for patients very desirable. This
is highly problematic from a logistical point of view, as even the larger
oxygen cylinders (H cylinders) have a limited supply when having to service
multiple patients. Providing liquid oxygen sources at alternative care
sites has been proposed, but presents a significant financial and engineering
challenge. Adequate supplemental oxygen supply remains an unresolved
issue at this point. One of the problematic concerns in establishing
a surge capacity alternative care site is the supply of supplemental
oxygen to patients. This need could conceivably be great since a significant
number of bio-weapons directly attack the respiratory track, causing
hypoxia. Oxygen is not on the supply list for any of the above caches.
There are various alternatives to supplying oxygen at an alternative
care site. Therefore, a separate description of the oxygen alternatives
As part of the RMBT Working Group discussions, a group of our Air Force
partners developed some potential solutions to addressing oxygen needs.
These may be viewed at www.DenverHealth.org/BioTerror/Document.htm under "Deployable
Oxygen Solutions" or at Tool 3. Given the variables of cost, general
availability, ease of use and sustainability, the most promising option
is also the simplest: a rack of interconnected "H" oxygen
cylinders, each supplying 7000 liters of oxygen. (A single "H" cylinder
could only supply 50 patients at 2 liters of oxygen per minute for 1
hour). Even this most basic of setups would require the rapid installation
of a rudimentary gas distribution system. Support for ventilated patients
would significantly increase the rate of oxygen consumption, further
complicating this issue and may not be possible.
The creation and utilization of any alternative care site will obviously
be successful only if a site can be staffed by necessary medical and
ancillary personnel. This may be a serious issue for several reasons,
two of which include:
- There is no guarantee that normally available
personnel would make themselves available to assist in a bioterrorist
- The simple fact that alternative sites are being implemented
implies that the normal health care system is running beyond capacity,
stressing routine levels of staffing.
Again, work done by the military
and presented in The Concept of Operations for the Acute Care Center lists proposed staffing for a 50-bed unit per 12-hour shift. This proposal
was adapted and augmented, including the addition of staffing levels
for non-infectious patients and quarantine (only) patients, by the RMBT
Working Group. Certainly, it is impossible to forecast absolute requirements
without knowing the acuity of patient illness, whether the disease process
is communicable or not, or if the unit is being used for quarantine only.
Advance regional planning could include establishment of a registry of
backup health care providers, such as those who are licensed but retired,
those working in an alternative line of work, or otherwise inactive.
An additional degree of preparation, since health care licensing is largely
a state issue, involves researching and drafting potential gubernatorial
orders to set aside specific aspects of state licensing requirements
for physicians, nurses and other health care providers. This
would allow easier incorporation of out-of-State professionals into an
expanded work core. Even with maximum planning, the establishment and
maintenance of a health care workforce for an alternative care site during
a bioterrorist event remains a daunting challenge.
A major problem in setting up and running an alternative care site would
be the provision of appropriately trained staff to run the site. Staffing
alternatives are best dealt with through advance planning. Some of the
steps required to enable this advance planning will require specific
State legal action, while other responsibilities will fall to local jurisdictions
and/or institutions in the area. Table 6 lists several items that will
facilitate obtaining and supporting additional staff for area hospitals
and alternative care sites. Table 7 lists estimated numbers of staff
necessary for an alternative care site 50 bed unit.6
5. Skidmore S, Wall W, Church J. Modular Emergency Medical System Concept of Operation for the Acute Care Center: Mass Casualty Strategy for a Biological Terror Incident, May 2003.
6.Adapted from The Concept of Operations for the Acute Care Center, the U.S. Army Soldier and Biological Chemical Command (SBCCOM), 2003, in press. Used by permission.
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